Little Talk Between Docs and Patients Pre-PSA Screen

Most men received limited information about potential benefits and harms prior to PSA screening tests, a retrospective review of a national database suggested.

From 2010 to 2015, about 60% of men recalled at least one element of guideline-recommended shared decision-making prior to testing. However, the proportion slipped to about 40% when all eligible men were considered (not just those who had recent tests) and to 10% among men undergoing PSA screening tests for the first time, according to Stacey A. Fedewa, PhD, of the American Cancer Society (ACS) in Atlanta, and colleagues.

Discussions skewed in favor of the advantages of testing decreased significantly during the study period, they reported in Annals of Family Medicine.

"Contrary to guidelines, many men receiving PSA testing still do not receive shared decision making, and only 1 in 10 men with no PSA test history received one or more elements of shared decision making," the authors concluded. "New and innovative strategies are needed to achieve more widespread application of shared decision making."

"There is this default that screening must be good -- always," Brawley, who was not involved in the study, told MedPage Today. "There is a tendency for people not even to acknowledge that men should make an informed decision about prostate cancer screening but that they should just have it."

Beyond the generalized support for prostate screening, most physicians do not have time for a thoughtful discussion with each man who is eligible for testing.

"You're supposed to see four or five patients an hour, move them in and move them out," said Brawley. "You're supposed to talk about their weight gain, their bad diet, their smoking history, and all of their other problems, and then you talk about the prostate. There just is not enough time to have those sorts of conversations."

Several organizations have published guidelines for PSA screening for prostate cancer, and the different guidelines vary with regard to specific recommendations. In general, however, the guidelines reflect the consensus that PSA testing should not occur without a discussion that results in shared decision-making between a clinician and a patient, Fedewa's group noted.

In 2012 the U.S. Preventive Services Task Force (USPSTF) recommended against routine PSA testing for men of all ages. Last year, the USPSTF published an update, recommending that clinicians inform men, ages 55 to 69, about the potential benefits and harms of PSA testing to help ensure that the decision to undergo testing is an individual one.

Previous studies showed that men undergoing PSA testing reported no discussion prior to testing or a discussion that focused only on the advantages or benefits of testing, the authors continued. Other studies documented variability in the adequacy of shared decision-making.

Whether adherence to principles of shared decision-making changed in response to recent changes in screening recommendations and practices remained unclear. To examine the issue, Fedewa's group analyzed data from the National Health Interview Survey for the years 2010 to 2015.

The analysis focused on men ages ≥50 and excluded those who had a history of prostate cancer or who had PSA tests for nonroutine reasons. The study population consisted of 9,598 men ages 50 to 64. Three-fourths of men were white, and a majority had health insurance. The proportion of men reporting a PSA test within the past year decreased from 38.1% in 2010 to 32.1% in 2015, and the proportion reporting a test more than a year ago increased from 19.2% to 23.2%.

The authors defined shared decision-making as a discussion that informed patients of the advantages and disadvantages of PSA testing and about the uncertainties regarding the test.

Across the entire study population, 37%-38% recalled receiving at least one element of shared decision-making in 2010 and 2015. In the subgroup of men who reported a PSA test within the past year, the proportion recalling at least one element of shared decision-making increased slightly from 58.5% in 2010 to 62.6% in 2015 (P=0.054). The percentage who reported full shared decision-making (including advantages and disadvantages of PSA tests) increased from 12.5% in 2010 to 17.4% in 2014 (P<0.001).

Among men who reported having a screening PSA test more than a year ago, 54.6% recalled at least one element of shared decision-making in 2010, increasing slightly to 56.8% in 2015. In the subgroup of men who never had a PSA test, the proportion recalling at least one element of shared decision-making was 10.3% in 2010 and 10.4% in 2015.

The likelihood that a men would be told only about the advantages of PSA testing declined by 18%, whereas the frequency of full informed decision making increased by 51%.

Study limitations included reliance on self-reported data and the possibility that some men may have answered the questions based on their own beliefs about PSA testing rather than what had been communicated to them by a physician, the authors noted.

The study was supported by the ACS Intramural Research Department.

Fedewa and co-authors disclosed no relevant relationships with industry.

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